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Methamphetamine Psychosis: Epidemiology and Management

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Methamphetamine Psychosis: Epidemiology and Management HHS Public Access Author manuscript Author ManuscriptAuthor Manuscript Author CNS Drugs Manuscript Author . Author manuscript; Manuscript Author available in PMC 2016 September 19. Published in final edited form as: CNS Drugs. 2014 December ; 28(12): 1115–1126. doi:10.1007/s40263-014-0209-8. Methamphetamine Psychosis: Epidemiology and Management Suzette Glasner-Edwards, Ph.D. and Larissa J. Mooney, M.D. UCLA Integrated Substance Abuse Programs Abstract Psychotic symptoms and syndromes are frequently experienced among individuals who use methamphetamine, with recent estimates of up to approximately 40% of users affected. Though transient in a large proportion of users, acute symptoms can include agitation, violence, and delusions, and may require management in an inpatient psychiatric or other crisis intervention setting. In a subset of individuals, psychosis can recur and persist and may be difficult to distinguish from a primary psychotic disorder such as schizophrenia. Differential diagnosis of primary versus substance-induced psychotic disorders among methamphetamine users is challenging; nevertheless, with careful assessment of the temporal relationship of symptoms to methamphetamine use, aided by state-of-the art psychodiagnostic assessment instruments and use of objective indicators of recent substance use (i.e., urine toxicology assays), coupled with collateral clinical data gathered from the family or others close to the individual, diagnostic accuracy can be optimized and the individual can be appropriately matched to a plan of treatment. The pharmacological treatment of acute methamphetamine-induced psychosis may include the use of antipsychotic medications as well as benzodiazepines, although symptoms may resolve without pharmacological treatment if the user is able to achieve a period of abstinence from methamphetamine. Importantly, psychosocial treatment for methamphetamine dependence has a strong evidence base and is the optimal first-line treatment approach to reducing rates of psychosis among individuals who use methamphetamines. Prevention of methamphetamine relapse is the most direct means of preventing recurrence of psychotic symptoms and syndromes. Long-term management of individuals who present with recurrent and persistent psychosis, even in the absence of methamphetamine use, may include both behavioral treatment to prevent resumption of methamphetamine use and pharmacological treatment targeting psychotic symptoms. In addition, treatment of co-occurring psychiatric disorders including depression and anxiety is important as a means of preventing relapse to methamphetamine use, which is often triggered by associated symptoms. 1. Introduction Studies of drug abuse trends in the Western U.S. indicate that methamphetamine (MA) use is a significant public health concern. According to the 2012 National Household Survey on Correspondence: Suzette Glasner-Edwards, Ph.D., Integrated Substance Abuse Programs David Geffen School of Medicine at UCLA, Semel Institute for Neuroscience and Human Behavior, 1640 S. Sepulveda Blvd., Suite 120, Los Angeles, CA 90024. Tel: 310 267-5206, Fax: 310 312-0552, [email protected]. Disclosures: Neither Suzette Glasner-Edwards nor Larissa Mooney has any conflict of interest. No sources of funding were used to assist in the preparation of this manuscript. Glasner-Edwards and Mooney Page 2 Drug Abuse approximately 1.2 million people (0.4 percent of the population) reported past- Author ManuscriptAuthor Manuscript Author Manuscript Author Manuscript Author year use of MA, and 440,000 (0.2 percent) reported using it in the past month [1]. Moreover, MA use is not only a problem in the United States, but is a growing concern in the global population. According to the World Drug Report set forth by the United Nations Office on Drugs and Crime, approximately 0.7% of individuals aged 15–64 years old worldwide (33.8 million people) reported using an Amphetamine Type Stimulant (ATS) in 2010, with MA being the most frequently used substance in its class [2], MA production and supply also appears to be on the rise [2], with more potent forms of MA increasingly available at lower cost [see 3]. Although rates of MA use have decreased from previous years (e.g., 0.3 percent reported past-month use in 2006), important vulnerable subgroups remain at risk for the development not only of MA use disorders but the severe and potentially debilitating psychiatric complications associated with MA use. Among the characteristics associated with heightened risk of MA use disorders are: residence in rural areas [e.g 4], Hispanic and Asian ethnicities [5], and, among males, gay or bisexual sexual orientation [6]. MA-related psychiatric symptoms are common, and include irritability, anxiety, psychosis, and mood disturbances [7]. Prominent psychotic symptoms among MA users include auditory and tactile hallucinations, ideas of reference, and paranoid delusions [7,8], and violent behavior is frequently linked with the latter [see 9]. Such symptoms and associated syndromes often produce progressive social and occupational deterioration as well as poor treatment outcomes [e.g., 10,11]. Because of the various etiologies that can give rise to psychotic symptoms and syndromes among individuals using MA, the clinical diagnosis and conceptualization of psychosis in MA users can be quite challenging. While psychotic symptoms are among the known possible consequences of MA use irrespective of any prior history of psychosis [8,12], use of MA among those with genetic vulnerability to psychosis or pre-existing psychotic disorders such as schizophrenia can lead to the onset or exacerbation of such conditions, respectively [see 13]. In light of these findings, coupled with research demonstrating greater levels of impairment, disability, and health service utilization among stimulant users with concomitant psychotic disorders [e.g., 14] clinical guidelines to facilitate accurate diagnosis and inform treatment considerations for MA- induced and substance-independent psychotic illnesses among MA users may have great utility. In this article, we explore the risk factors, clinical features, and differential diagnostic considerations for understanding MA psychosis. We then highlight important prevention and treatment implications for individuals whose psychosis is transient (but who remain at risk for persistent psychosis) as well as those with a more pervasive, recurrent, or chronic presentation of psychotic symptoms. Articles for inclusion in this review were identified through an extensive literature search conducted in April 2014 (and repeated in September of 2014) in PubMed and national survey databases. Search terms included “methamphetamine (or “amphetamine,” when appropriate),” “psychosis,” and domain specific terms such as “epidemiology,” “treatment,” “genetics,” “diagnosis,” and “risk factors.” Extant diagnostic and other clinical guidelines available in the U.S. and internationally were reviewed. Efforts were made to incorporate the most recent reports and reviews in the field to provide an updated summary of the current knowledge about diagnosis and treatment of MA psychosis. CNS Drugs. Author manuscript; available in PMC 2016 September 19. Glasner-Edwards and Mooney Page 3 Author ManuscriptAuthor 2. Manuscript Author Clinical Features Manuscript Author of Psychosis Manuscript Author in Methamphetamine Users According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [15], an episode of psychosis that occurs in the context of MA (or other substance) use can be considered a primary psychotic disorder (eg., schizophrenia) under the following conditions: (1) symptoms are substantially in excess of what would be expected given the type or amount of substance used or the duration of use; (2) there is a history of psychotic episodes that are not substance-related; (3) psychotic symptom onset precedes the onset of substance use; (4) psychotic symptoms persist for at least one month after the cessation of intoxication or acute withdrawal [15]. By contrast, the presence of a substance-induced psychotic disorder is diagnosable when the following symptoms are present: (1) Presence of prominent hallucinations or delusions; (2) Hallucinations or delusions develop during, or soon after, intoxication or withdrawal from a substance or medication known to cause psychotic symptoms; (3) Psychotic symptoms are not actually part of a psychotic disorder (such as schizophrenia, schizophreniform disorder, schizoaffective disorder) that is not substance- induced (i.e., if psychotic symptom onset was prior to substance or medication use, or persists longer than one month after substance intoxication or withdrawal, then another psychotic disorder is likely); (4) Psychotic symptoms do not only occur during a delirium. Likewise, the criteria used outside of the U.S., based upon the International Classification of Diseases diagnostic system (ICD-10), distinguish substance-induced psychotic symptoms from schizophrenia as follows: “Schizophrenia is a disorder that is characterized by at least one psychotic symptom (or two symptoms if not clear cut) that last for more than a month, and is not related to drug intoxication or withdrawal” [16]. Despite the tendency in some countries to avoid assigning a diagnosis of schizophrenia in certain cases of long-term psychosis with onset in the context of MA use (e.g., Japan), the international diagnostic approach to distinguishing these syndromes is similar to that utilized in the United
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